Any downside to mastectomy post lumpectomy?

Rubytoos · November 2017

I have a hopefully indolent, rare, in situ papillary carcinoma. It is small and sits against my chest wall directly over my heart (left breast). I have a heart condition brought on by viral pericarditis and do not want to have rads. My treatment team suggested lumpectomy with 15 treatments--no sentinel node biopsy, no follow on chemo or endocrine therapy. For me there is no upside to having radiation when a mastectomy would likely give me the same or better outcome. However, per my oncologist there is always the chance that my cancer could be upgraded and no one will know until they have all of it out. My thinking is this: If they come back to me with information that indicates my tumor was not the indolent non aggressive thing it appears, I might rethink treatment, including radiation. But right now, for peace of mind, I am thinking ultimately, mastectomy. My oncologist stressed that based upon the information they currently have I must accompany a lumpectomy with radiation and for me that is a deal breaker.

I know people often have mastectomy later in their treatment plan, after a lumpectomy. Is there any downside to having a lumpectomy first and then scheduling a mastectomy other than the obvious scenario of having two surgeries versus one? I ultimately want to have skin and nipple sparing surgery and an implant on the affected side. I have said this to the breast surgeon and oncologist and radiologist, but there is a full court press to convince me to have radiation versus more surgery so I don't think they are thinking along these lines.

Part of me wants to wait a little longer and just have a mastectomy. Although this was diagnosed a month ago, the tumor has been there for at least three years per previous imaging. It grew very little, but now it has been shredded by core biopsy and I want it out. Maybe this is not as urgent as I am feeling and I should just pull back and schedule a mastectomy after the first of the year? Or maybe get the results of the lumpectomy--however, unless they come back saying the lesion is benign, and the pathologist was emphatic that it was in fact carcinoma, I think I am faced with the same decision. So maybe better all around to wait and have the mastectomy? I am under so much pressure I really cannot think straight and ALL my team comes back with is radiation and have not accepted this is a deal breaker for me.

lekker · November 2017

I had a lumpectomy with SNB then decided to have a bilateral mastectomy. The one issue that comes immediately to mind is that if you have a lumpectomy first, that may dictate where the mastectomy incisions are placed. My incisions were affected by the prior lumpectomy scar and were not ideal from a cosmetic perspective. It doesn’t really bother me but it might be something to consider if you know you want the mastectomy anyway.

Icietla · November 2017

Hi Rubytoos. I am so sorry about your illnesses. I understand your being dreadful of radiation treatment.

It does not make sense to delay your treatment surgery needlessly. You have breast cancer. The longer you wait to start your treatment, the more advanced your disease state can become.

It would not make sense to put the necessarily involved time, efforts, and other resources into having a lumpectomy if you would want a mastectomy anyway.

Might not your heart condition make the difference that once you have had your (necessary) treatment surgery, you might have difficulty finding a Surgeon willing to do any elective surgeries for you? With or without complications, breast reconstruction can take a series of surgeries.

Have you checked with your Surgeon/s to find out whether skin- and nipple-sparing mastectomy surgery is an appropriate option for your case? You may have to choose between (typical) mastectomy surgery and parts-sparing breast-conserving surgery.

Even with mastectomy surgery, the location of your tumor may make radiation treatment necessary. Have you asked your Care Team -- if you have mastectomy as your treatment surgery, would your tumor's presently apparent proximity to your chest wall make radiation treatment necessary anyway? or only if invasion of your chest wall is found? and would they advise radiation treatment anyway if any nodes are found to be diseased?

Would your preference for mastectomy depend on its (possibly?) permitting you to avoid radiation treatment? Would your preference for mastectomy depend on its being the parts-sparing type? Would it depend on your likely prospects for future elective surgeries?

I know the decision is very difficult. So sorry I cannot make it any easier for you.

Icietla · November 2017

Here is BCO's article on the study to which you referred in your other thread.

http://www.breastcancer.org/research-news/best-surgery-for-early-stage-may-depend-on-age

Sourisou · November 2017

Hi Rubytoos, we are in a fairly similar boat, as I was diagnosed on 13/10 with encapsulated papillary carcinoma with associated DCIS.

To answer your question if there is a downside to having a lumpectomy before a mastectomy, yes there can be. I first received a lumpectomy at the end of September for an "atypical papilloma" that was then upgraded to DCIS/EPC after analysis. My surgeon wasn't expecting a malignant result and made a nice incision around the areola, thinking it would be it and heal nicely. Unfortunately, I had to have re-excision. Unlike you, I can't have radiotherapy since I had some already 18 years ago for another cancer (and my actual breast cancer is most likely radio-induced). So I had no choice to have a UMX. I wanted a nipple-sparing one but because of the nipple scaring (not properly healed yet) there was neither a good vascularisation nor an acceptable aesthetic result, so they had to remove the nipple. Not the end of the world but if I had known the outcome, I would have asked for a different incision site for the lumpectomy.

I didn't want the UMX but now I don't regret it. I had it on 31/10 and feel great - virtually no pain, just some muscle soreness and only when I move; I was off narcotics on the 3rd day. I had direct-to-implant, submuscular, skin-sparing with alloderm. I know everyone has a different threshold of pain, different experience and different surgeons, but I was expecting a monster and it wasn't that bad. I would still have taken the radiotherapy if I had the choice, although it already gave me skin cancer last year and breast cancer this year! So your health concerns are very valid - I believe radiotherapy is a great treatment that saves many lives, but that can also carry long term health issues. Take your time to ponder your decision. Hugs and love to you xx

Rubytoos · November 2017

Thank you all for your replies. They are very helpful. Sourisou, did you have a biopsy prior to your lumpectomy? My oncologist does say that my tumor might be "upgraded" and that might drive different treatment options. As I mentioned, the available information indicates papillary carcinoma in situ but papillary carcinoma appears to be somewhat challenging from a diagnostic standpoint.

NotVeryBrave · November 2017

One of my considerations in choosing my surgery was to avoid radiation if possible. Since there is always that unknown, one BS said she could do the lumpectomy first and if no nodes were involved and I still didn't want radiation then she could go back later to do the mastectomy. She did say that I would have an additional scar and healing from the MX could be impacted. At least she listened. I guess she would have felt bad if I chose MX to avoid rads and then still had to do them.

I ended up deciding to go straight to BMX for a number of reasons. I really didn't want to have multiple surgeries. Or to continue to "watch" some things in the other breast.

Sourisou · November 2017

Rubytoos, yes I had a few biopsies before the lumpectomy. First I had stereostatic biopsy for 2 areas of suspicious calcs on mammogram (in the DCIS area, something was brewing there for sure) - they came back as benign adenosis. The doc thought everything was fine but ordered a routine MRI (since I'm considered high-risk) - the MRI lit up in my upper inner quadrant. I then had a diagnostic ultrasound, where the doc found an "enlarged duct with debris in it"; she did a core biopsy that came back as atypical papilloma... still not cancer. But since there was a large area on MRI and that atypia can coexist with malignant cells, they did the lumpectomy, and the rest is history!

Molly50 · November 2017

I had umx after lumpectomy. If my team had pushed for an MRI before surgery I could have avoided the extra surgery. I had two positive nodes so I ended up with radiation after mastectomy anyway. I say go for the umx.

Anonymous · November 2017

I just read a book written by a breast cancer surgeon and she had some great insight into this disease. Years ago, researchers found a mouse mammary tumor virus that causes breast cancer in mice. Since then, there's been research done that finds a lot of similarities between the virus in mice and a human virus. If scientists can determine that a virus causes breast cancer in humans, they could make a preventive vaccine and put an end to breast cancer.

The book I read is called "The End of Breast Cancer: A Virus and the Hope for a Vaccine" by Dr. Kathleen Ruddy. The breast cancer surgeon also talks about her work with patients and how important it is to prevent this disease. Check out Amazon if you want to get a copy of this book!

Any downside to mastectomy post lumpectomy?

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